56220 Eligibility for Programs and Services.
If you are a returning student and
have been previously assigned an Alternate Identification Number by the district, please complete. Otherwise leave blank.
6. This application is for:
Fall
Winter
Spring
Summer
Year _________
2. Social Security Number
Students are required by law to provide their Social Security Number, which will be used for reporting to the federal government under the Taxpayer Relief Act of 1997 and for financial aid verification. If you do not have a Social Security number, or if you do not wish to use it, please leave blank.
4. Legal Address/Residence (Do not use P.O. Box or Business Address)
_______________________________________________________________________
Number Street Apt. No.
_______________________________________________________________________
City State Zip Code
I have lived at this address since: ____________________________________________________ Month Day Year
7. Sex
Female
Male
8. Birth Date Age
_______________________________ __________________________ Month Day Year Month Day Year
9. If you have lived at your present address fewer than two years, list previous address(es)
__________________________________________________________________________________ Number/Street/Apt. No. City/State FROM: Mo/Yr TO: Mo/Yr ________________________________________________________________________________ Number/Street/Apt. No. City/State FROM: Mo/Yr TO: Mo/Yr
13. Contact Information
Primary Telephone: (________) _______________
Area Code Number
E-mail:
___________________________________________________
10. Mailing Address (if different from Legal Address given above)
____________________________________________________________________________________
Number/Street/Apt. No. City/State Zip Code
14. Place of Birth
____________________________________________________
City State or Foreign Country
8 8 157
11. My present stay in California began on: ____________________________________________
Month Day Year Are any of the following on active military duty? (Please check all that apply)
Yourself
Spouse
Parents15. Full name of the most recent High School you attended
_______________________________________________ Name of High School
_______________________________________________ City State or Foreign Country
12. The questions below must be answered by every applicant.
At any time in the past two years have you: (If you are under 19, answer for your parents)
* Registered to vote in a state other than California? ………..…. Yes No If yes, what year? ___________ * Filed a legal action in a state other than California? …….……..…….. Yes No If yes, what year? ___________ * Attended a non-California college/university as a resident of that state? Yes No If yes, what year? __________
* Filed as a Non-Resident for California State Income Tax Purposes? …. . Yes No If yes, what year? __________
16. Last College attended. If none, check box:
___________________________________________________ Name of College Dates Attended ___________________________________________________ ________
City/State/Foreign Country Degree Awarded
17. I am a citizen of
__________________________________________ Country
The LACCD is made up of the following schools. Please check ONE school.
City
East
Harbor
Mission
Pierce
Southwest
Trade Tech
Valley
West LA
ITV18. If you are not a United States Citizen, please circle and complete:
2. Permanent Resident Alien _______________________ 3. Temporary Resident Alien Permanent Resident or Visa No. 4. Refugee, Asylee
5. Student Visa (F-1 or M-1 visa) __________________________ 6. Other (Specify): ________________ Issue/Adjustment Date 7. Visitor Visa (B-1 or B-2 visa)
OFFICE USE
ONLY Residence Matriculation High School
College Concurrent
19. Complete this question only if you are under 19 and have never been married.
Name of Parent or Legal Guardian: ______________________________________ Relationship to you:
□
Father□
Mother□
Legal Guardian□
Other _____________ Is the person a:□
U.S. Citizen□
Permanent Resident Alien□
Other _____________ If a Permanent Resident Alien, enter “A-Number” and date of issue: ______________ Current residence of this person: __________ From: __________________ To: PRESENT State Month/Year24. Highest Education Status: Please enter number and year in boxes
below
1 = Earned a U.S. High School diploma (or will earn one before college semester begins) 2 = Enrolled in grade 12 or below when college semester begins
3 = Not a High School graduate, currently enrolled in adult school 4 = Not a High School graduate, last attended High School
5 = Passed the GED or received a certificate of H.S. equivalency Number 6 = Earned California High School Proficiency Certificate
7 = Earned a Foreign Secondary diploma or certificate of graduation 8 = Earned an Associate degree
9 = Earned a Bachelor’s or higher degree Year 20. Ethnic Identity (*) Please enter number in box
10 = Chinese 20 = Black, African-American
11 = Japanese 30 = Filipino 60 = American Indian, Alaskan Native 12 13 = Korean = Laotian 40 = Mexican, Chicano, Mexican-American 70 71
= Pacific Islander; Samoan = Pacific Islander; Hawaiian 14 = Cambodian 41 = Central American 72 = Pacific Islander; Guamanian 15 = Vietnamese 42 = South American 79 = Other Pacific Islander 16 = Indian Sub-Continent 49 = Other Hispanic 80 = Other Non-White 19 = Other Asian 50 = Caucasian, White 90 = Decline to state
25. Enrollment Status: Please enter number in box 1 = First time college student
2 = First time at this college, after attending another college 3 = Returning to this college, after attending another college 4 = Returning to this college, without having attended another college 5 = Enrolling in this college, while attending school in the 12th or lower grade
26. College Units or degree completed by first day of this term
Please enter number in box
1 = 0 units 4 = 30 to 59 ½
2 = 1 ½ to 15 ½ 5 = 60 or more units, no degree 3 = 16 to 29 ½ 6 = A.A., A.S., B.A., B.S. or higher degree
21. What is your primary language? (*) Please enter number in box 1 = English 5 = Filipino
2 = Armenian 6 = Japanese 9 = Spanish 3 = Chinese 7 = Korean 10 = Vietnamese
4 = Farsi 8 = Russian 11 = Other language ______________________________
27. Veteran (Leave blank, unless you are a veteran)
Were you honorably discharged from the U.S. Armed Forces? □ Yes □ No 22. What is your main educational goal? Please enter number in box
1 = Prepare for a new career (acquire new job skills) 2 = Advance in current job/career (update job skills) 3 = Discover/develop career interests, plans and goals 4 = Obtain a two-year vocational degree without transfer 5 = Obtain a two-year Associate degree without transfer 6 = Obtain a vocational certificate without transfer
7 = Obtain a Bachelor’s degree after completing an Associate’s degree 8 = Obtain a Bachelor’s degree without completing an Associate’s degree 9 = Maintain certificate or license (e.g. Nursing, Real Estate)
10 = Improve basic skills in English, reading or math 11 = Complete credits for high school diploma or GED 12 = Personal development (intellectual, cultural) 13 = Undecided on goal
14 = To move from noncrredit coursework to credit coursework 15 = Complete 4 year college requirements
28. Student Information -- Permission to Release
TYPES OF STUDENT INFORMATION: According to the Los Angeles
Community College District (1) Directory of Information: Includes your name; city of residence; participation in officially recognized activities and sports; weight and height of athletic team members; dates of attendance; degrees and awards received; and the most recent previous educational institution attended. (2) College Foundation Information: Includes your name, address, telephone number. 3) Four-year College Information: Includes your name, address, and telephone number. 4) Military Recruiting Information: Includes “Directory information” plus address, telephone number, date of birth, and major field of study.
I do not permit the college to release directory information
(Leave blank if you want information on LACC Foundation scholarships, grants, and networking opportunities)
I do not permit the release of information to the College Foundation I do not permit the release of information to four-year colleges I do not permit the release of information to the military
You may change your Directory Release at any time by completing a Release of Directory Information form and returning it to the Admissions Office.
23. Special Services (*)
The Los Angeles Community College District is committed to increasing your educational success. Each area listed below provides special services. Please indicate those services that interest you.
1. □ Financial Aid 5. □ Emplo ment Assistance
2. □ Child Care 6. Information regarding special services and/or accommodations for students 3. □ Tutoring with disabilities may be obtained from the Disabled Student Programs 4. □ Transfer Assistance
7.
Programs (DSPS) Office.
Are you from a low income family and in eed of special counseling, tutoring and/or financial aid assistance? □ Yes □ No